16 November 2022
During a routine inspection
We previously inspected this service on 15 June 2022, and rated the service overall as requires improvement. Following the inspection in June 2022 we issued the provider with a warning notice for Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment. We also issued the provider with two requirement notices for Regulation 11 HSCA (RA) Regulations 2014 Consent and Regulation 17 HSCA (RA) Regulations 2014 Good governance.
We carried out a focussed responsive inspection at Cotton Exchange on 16 November 2022 as a follow up to the warning notice that was issued in June 2022. During this inspection we found there had been some improvements since the last inspection and the provider had addressed the concerns raised in the warning notice from the previous inspection.
This inspection was not rated. We found that:
- The service had changed the way they monitored mandatory training. At the time of our inspection staff compliance with mandatory training was 100%.
- The service had taken steps to ensure specialist equipment was regularly serviced and maintained.
- The service had taken steps to control infection risk. The service introduced new processes to protect women, themselves, and others from infection risks.
- The service introduced new processes to collect outcome data and monitor the quality of scans.
- The service now provided up-to-date risk assessments for women to remove or minimise risks.
- The service had acted on our recommendations to ensure policies were reviewed regularly and in line with best practice guidelines.
- The service now had evidence of staff appraisals for work performance, supervision meetings and development support for staff.
- The service had made changes to support women to make informed decisions about their care and treatment.
- Leaders now monitored the effectiveness of the service. Staff had formal meetings to discuss and learn from the performance of the service.
- Leaders had developed a defined risk register with risks that were rated or graded in terms of impact or likelihood
- Leaders had introduced systems to manage performance effectively. Leaders were able to identify and escalate relevant issues and identify actions to reduce their impact.
- The service had introduced processes to collect reliable data and analyse it to understand performance, make decisions and improvements.
However:
- The provider did not display information on how to raise a complaint and signpost appropriately.
- Consent was not always recorded in line with the services own policy.